The problems at Veterans Affairs extended far beyond long wait lists. A report today showed the department is plagued with poor care that has cost up to 1.000 veterans their lives, and left American taxpayers on the hook for nearly $1 billion in malpractice settlements since 2003.

Senator Tom Coburn reports that “the problems at the VA are worse than anyone imagined.” Dozens of veterans have died while stuck on secret waiting lists at a VA facility in Phoenix. An inspector general’s investigation has found widespread misuse of secret wait lists in a number of facilities.

Senator Coburn’s report, titled “Friendly Fire: Death, Delay and Dismay at the VA,” argues that problems go back well beyond the Phoenix scandal and run far deeper than phony wait lists and scheduling practices designed to demonstrate that managers were meeting their performance goals. His report details dreadful cases.

A Philadelphia vet went in for a tooth extraction. Doctors went ahead despite his dangerously low blood pressure. On the way home from the operation, he had a stroke and was paralyzed. A vet in South Carolina had to wait nine months for a colonoscopy. By the time he had the procedure, he was diagnosed with stage three cancer. The VA admitted that had he been treated earlier his case might not have been so severe. Another veteran had annual chest X-rays, but doctors never spotted a growing lesion in his lung. It ultimately killed him.

Some legislators recommended more financing, as usual, but the problem can be traced back to bad management and lax working standards, not to lack of money. In one finding, Coburn said, VA doctors average about half the workload that private-practice primary care physicians do. He added:

Female patients received unnecessary pelvic and breast exams from a sex offender. The VA is way behind on processing disability claims and constructing facilities. Some VA health care providers have lost their medical licenses, but the VA hid that information from patients. The federal government has paid out $845 million for VA medical malpractice settlements since 2001.

A security chief, Richard Meltz, head of security at the Bedford VA Medical Center pleaded guilty in January in involvement in what the FBI called “two sadistic kidnapping, rape and murder conspiracies.” He also advised two others on how to avoid being tracked, such as not using toll roads, and where to dump bodies.

The FBI says it has opened a criminal investigation of the Veterans Affairs Department. The Bureau’s Phoenix office has joined an ongoing review by the VA inspector General.

Somme of the reasons for the chronic problems include a bonus system that rewarded managers for meeting goals regarding access to treatment. The audit findings, covering 731 VA facilities nationwide and based on interviews with more than 3,700 staff members, said a 14-day goal instituted by the Obama administration, for providing care to newly enrolled veterans proved “simply not attainable” due to growing demand and lack of capacity. “Imposing this expectation the field before ascertaining the resources required represent an organizational leadership failure.

The audit portrayed 57,436 newly enrolled veterans facing a minimum 90-day wait for medical care, 63,869 veterans who enrolled over the past decade requesting an appointment that never happened. A patient who had been admitted for “significant and chronic mental health issues” lived in the 106 bed facility for eight years before he received his first psychiatric evaluation.

Well meaning bureaucrats had no other way to measure the effectiveness of VA Hospital care—than wait times, so they gave them 14 days maximum wait time for a veteran to be seen by a medical professional. That’s the way it works in large government bureaucracies.